CMS/EIP Fiscal Report Center: 06
Services beginning 01/01/2022 ending 03/31/2022 Date of Report:04/16/2022 Page: 1
List order: No List
Payclass Filters:TPIN
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 4 7.500000 562.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 3 5.500000 412.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 3 5.000000 277.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 27 48.500000 3637.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 85 143.500000 10383.2500 72.3571
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 17 28.500000 2137.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 51 83.500000 6233.2500 74.6497
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 7 13.500000 1012.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 31 47.000000 3525.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 20 35.500000 1970.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 72 124.000000 6660.0000 53.7097
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
Subtotal (Total Children Is Unduplicated) 164 549.500000 37345.0000 67.9618
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EI Services,Class #03
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 3 4.000000 200.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 12.000000 600.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 20 70.750000 5045.0700 71.3084
OCCT-97530GT-OT SESSION BY LICENSED OT 4 10.000000 649.2300 64.9230
OCCT-97530HM-OT SESSION BY OT ASST 8 47.000000 2264.8000 48.1872
OCCT-97530HMGT-OT SESSION BY OT ASST 1 4.000000 228.8000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 26 93.000000 6582.6300 70.7810
PHY-97110GT-PT SESSION BY LICENSED PT 4 13.000000 928.7200 71.4400
PHY-97110HM-PT SESSION BY PT ASST 9 36.500000 2078.1400 56.9353
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 4 7.250000 414.4100 57.1600
SENS-V5264-EARMOLD 2 2.000000 36.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 64 252.250000 20995.0200 83.2310
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 31 86.500000 5726.4400 66.2016
Subtotal (Total Children Is Unduplicated) 141 638.250000 45749.2600 71.6792
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Total 1187.750000 83094.2600 69.9594
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Number of Children (Unduplicated) With at Least One Service 295
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Center 06
Flag Claims Units Chgs Paid
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R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 522 320.000000 20502.3000 20502.3000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
870 867.750000 62591.9600 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1392 1187.750000 83094.2600 20502.3000